2016-2017 Massachusetts Application for Free and Reduced Price School Meals If you have received a Notice of Direct Certification from the school district for free meals, do not complete this application. But do let the school know if any children in the household are not listed on the Notice of Direct Certification letter you received.
STEP 1
List ALL Household Members who are infants, children, and students up to and including grade 12 (if more spaces are required for additional names, attach another sheet of paper)
Definition of Household Member: “Anyone who is living with you and shares income and expenses, even if not related.” Children in Foster care and children who meet the definition of Homeless, Migrant or Runaway are eligible for free meals. Read How to Apply for Free and Reduced Price School Meals for more information. Student? Homeless Migrant Runaway Foster
MI
Child’s Last Name
School Name
Grade
Child’s First Name
Circle Yes or No
Check all that apply
Y N Y N Y N Y N Y N Y N STEP 2
Do any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR?
Write the Agency ID Number, then go to STEP 4 (Do not complete STEP 3)
STEP 3
ReportIncomeforALLHouseholdMembers
Do not provide EBT card number.
Agency ID Number:
(Skipthisstepifyouanswered‘Yes’toSTEP2)
Review the charts titled “Sources of Income” for more information. The “Sources of Income for Children” chart will help you with the Child Income section. The “Sources of Income for Adults” chart will help you with the All Adult Household Members section
How often?
Child Income
A. Child Income
Sometimes children in the household earn or receive income. Please include the TOTAL income received by all Household Members listed in STEP 1 here:
B. All Adult Household Members (including yourself)
Weekly
$
Bi-Weekly
2x Month
Monthly
List all Household Members not listed in STEP 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total gross income (before taxes) for each source in whole dollars (no cents) only. If they do not receive income from any source, write ‘0’. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.
Name of Adult Household Members (First and Last)
How often? Weekly
Bi-Weekly 2x Month
Monthly
Last Four Digits of Social Security Number (SSN) of Primary Wage Earner or Other Adult Household Member
Total Household Members (Children and Adults)
STEP 4
Earnings from Work
Public Assistance/ Child Support/ Alimony
XXX-XX-
How often? Weekly
Bi-Weekly 2x Month
Monthly
Pensions / Retirement / All Other Income
How often? Weekly
Bi-Weekly 2x Month
Check if no SSN
Contact information and adult signature
“I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that school officials may verify (check) the information. I am aware that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.”
Street Address (if available)
Printed name of adult signing the form
Apt #
City
Signature of adult
State
Zip
Daytime Phone and Email (optional)
Today’s date
Error prone
Monthly
INSTRUCTIONS
Sources of Income Sources of Income for Adults
Sources of Income for Children Sources of Child Income
Example(s)
- Earnings from work
- A child has a regular full or part-time job where they earn a salary or wages
- Social Security - Disability Payments - Survivor’s Benefits
- A child is blind or disabled and receives Social Security
-Income from person outside the household
- A friend or extended family member regularly gives a child spending money
-Income from any other source
- A child receives regular income from a private pension fund, annuity, or trust
OPTIONAL
benefits
- A Parent is disabled, retired, or deceased, and their child receives Social Security benefits
Earnings from Work - Salary, wages, cash bonuses - Net income from self-
employment (farm or business) If you are in the U.S. Military: - Basicpayandcashbonuses (do NOTincludecombatpay, FSSAor privatizedhousing allowances) - Allowancesforoff-base housing, foodandclothing
Public Assistance / Alimony / Child Support - Unemployment benefits - Worker’s compensation - Supplemental Security Income (SSI) - Cash assistance from State or local government - Alimony payments - Child support payments - Veteran’s benefits - Strike benefits
Pensions / Retirement / All Other Income - Social Security (including railroad retirement and black lung benefits) - Private pensions or disability benefits - Regular income from trusts or estates - Annuities - Investment income - Earned interest - Rental income - Regular cash payments from outside household
Children's Racial and Ethnic Identities
We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children’s eligibility for free or reduced price meals. The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules. In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Hispanic or Latino
American Indian or Alaskan Native
Native Hawaiian or Other Pacific Islander
Not Hispanic or Latino
Asian Black or African American
White
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410 fax:
(202) 690-7442; or
email:
[email protected].
This institution is an equal opportunity provider.
For School Use Only 2016-2017 Massachusetts Application for Free and Reduced Price School Meals Total Income
Household Size
Eligibility:
Annual Income Conversion:
Only annualize income if there are multiple pay frequencies How often? Weekly
Bi-Weekly
2x Month
Monthl
Weekly Every 2 Weeks Twice A Month Monthly
x 52 x 26 x 24 x 12
Free
Reduced
Categorical Eligibility Denied
Annually
Determining Official’s Signature
Date
Confirming Official’s Signature
Date
Verifying Official’s Signature
Date
